Basic Information
| Provider Information | |||||||||
| NPI: | 1083673123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | STEVE | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1507 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765281024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548658251 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1507 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765281024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548658251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2006 | ||||||||
| LastUpdateDate: | 01/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | PY0466 | NV | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC0700X | 36884 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 36884 | 01 | TX | STATE LICENSING BOARD | OTHER | 100503261 | 05 | NV | MEDICAID |